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Armed Forces: Medical Records

Volume 458: debated on Monday 12 March 2007

To ask the Secretary of State for Defence (1) what systems are in place to catalogue and account for medical records of British service personnel; (121519)

(2) how many British service personnel's medical records are missing.

A complete medical record is maintained for every member of the armed forces. This facilitates where necessary any ongoing medical treatment and supervision wherever the individual is serving, and provides an audit trail of responsibility for those engaged in the care and treatment of patients.

The custody and security of medical and dental documents of all personnel is the responsibility of the senior Medical Officer (MO) or (for the Navy) the Medical Branch Rating (MBR) of the establishment or ship in which the individual is serving. To prevent breaches of medical confidentiality, accidental or otherwise, all medical records are kept secure at all times. They are not kept in the possession of any person other than the MO or medical staff in the course of their duties. When not in use all such documents, notes, correspondence and external media used to store medical data are kept in a locked container.

Quarterly musters of all medical records held are carried out in all primary care units against unit nominal lists, and more frequently when required (e.g. when a unit is formed or deployed). During musters, medical records are scrutinized by physically inspecting the main service medical record known as “F Med 4” form which are a series of documents which record an individual’s medical history. These are cross-checked against other records to ensure that personnel remain in-date; records are accurate; and no treatments or appointments are outstanding. Scrutiny of medical records is carried out on receipt of a new “F Med 4” and on notice of drafting or deployment.

When an individual is receiving secondary-care treatment in an NHS hospital, any medical notes are the responsibility of the NHS Trust where the treatment is taking place. When an individual is discharged from hospital, the hospital discharge report is enclosed in the “F Med 4”, along with other clinical reports such as Laboratory, Physiotherapy and X-ray. The same procedures apply for documentation from MOD Regional Rehabilitation Units, Departments of Community Mental Health and other directly managed units such as the Defence Medical Rehabilitation Centre at Headley Court.

There is currently no centrally available source of information regarding the number of missing medical records, and the information could be obtained only at disproportionate cost. The information could be obtained only by requesting every military medical centre in the UK and overseas to provide details of records not held at their last quarterly medical records muster.